Older Driver Safety Awareness

Screening/Evaluations
 
Driving is a very complex activity that requires specific physical, visual and cognitive abilities.  As we age, those abilities change in sometimes subtle and sometimes drastic ways.  For example, an older driver may begin to have difficulty seeing to drive at night, but have no problem during daylight hours.  Or a stroke or other illness may make it so difficult to process visual information that safe driving is impossible.  The thing is, we all age at different rates.  So unless there is a sudden and drastic change in our abilities, we may not realize that we are declining.
 
Most of us go to the doctor for regular check-ups.  But it is just as important to get a check-up for driving fitness.  After all, driving is our main way to stay connected to the community and our key to independence.
 
At work this morning, an elderly patient stated that she thought there have been changes in her driving abilities but wondered how she could check.  The first thing you can do for yourself is a self-assessment.  This can be a useful educational tool to identify potential challenges to your driving health.  Then, if you are concerned about the results of the self-assessment, it is important to consider undergoing a comprehensive driving evaluation from an occupational therapy driver rehabilitation specialist.  I understand that this can be extremely intimidating.  After all, who of us does not feel intimidated when our performance is being evaluated?  But I, as I am sure is true of my colleagues, do not go into an evaluation with the idea of "taking away" someone's drivers license.  Instead, we look for strengths to build on to keep the individual driving safely for as long as possible.
 
To learn more about self-assessments, go to www.AAASeniors.com [5] and check "Skills Assessment."
 
To learn more about comprehensive driving evaluations, go to www.thehartford.com/alzheimers. [6]  Scroll down and check "Comprehensive Driving Evaluations" on the left side of the page.
 
Tomorrow we will touch on driving equipment and adaptations.

Drive safely and keep the rubber side down!  ~~ Karen

Driving Equipment/Adaptations

After the evaluation, there are usually 4 different outcomes that are possible.  They are:

1. Safe to drive.
2. Marginally safe but would benefit from adaptive equipment and/or additional training.
3. Unsafe, but may be appropriate to continue driving with additional training.
4. Unsafe to drive.

Any intervention is based on a plan that is agreed upon between the client and the driving specialist/therapist.  The goal of intervention is to explore ways for individuals to drive safely for as long as possible.  After the assessment, if adaptive equipment is recommended, the occupational therapist will trial different pieces of equipment and provide additional training as needed so the client is able to use it safely.  This equipment could include such things as wide-angle mirror, spot mirrors, seat cushions, left-foot gas pedals, hand controls or different steering devices.  Sometimes it is something as simple as teaching a different strategy to turn on the key or to change gears or operate secondary controls such as the heater, air conditioner or turn signal.
 
CarFit is a free, community-based program designed to enhance your comfort and safety while driving.  Occupational therapy practitioners are on-site to recommend potential solutions that may help you.  You may read the free brochure and sign up for an event near you on the AAA website at www.AAASeniors.com. [11]
[11]
Alternately, you can go on the ADED (Association for Driver Rehabilitation Specialists) website to find a Certified Driver Rehabilitation Specialist to ask specific questions or to schedule an evaluation.  The website is: www.driver-ed.org [12].

Tomorrow we will talk about taking changes in stride.  Until then ~~
Drive safely and keep the rubber side down! ~~ Karen

Taking Changes in Stride
 
     The ability to drive safely can be affected by changes in our physical, emotional and mental conditions.  Although some of these changes take place as a normal part of aging, they occur individually and at different times.
 
     Age alone is not a good predictor of driving safety or ability.  In my work as a driver rehabilitation therapist, I have seen individuals of varying ages on a driving skills course.  Some 80-year-olds were able to safely and proficiently complete the course when some 60-70-year-olds were not.  But safety research clearly shows that declines in our physical, emotional and mental abilities may increase the crash risk or increase unsafe driving behaviors.
 
     One key to safe driving is knowing when we or another driver are at increased risk.  To be knowledgeable and make wise choices we must be attentive and know what to look for.  For example:

1. Being distracted by a stressful day or perhaps a serious illness of a loved one.
2. Having a series of minor accidents.  Or observing multiple scrapes or small dents in someone's car.
3. Having wandering thoughts or being unable to concentrate.
4. Being unable to read ordinary road signs.
5. Getting lost on familiar roads, or not being able to navigate during rain, fog or snow.
6. Having other drivers honk at you frequently.
7. Being spoken to about your driving by family, friends or the police.

     Reading this list is not enough --- you MUST be honest with yourself.  The consequences of a crash can be devastating emotionally, physically and financially to the driver, to passengers, to family members and to other drivers on the road.
 
     Visit the National Highway Traffic Safety Administration's (NHTSA) web page, Driving Safely While Aging Gracefully or AAA's Older and Wiser Driver to read more about the changes that can affect safe driving and the signs that indicate the need to take a closer look at a person's driving.  You can type in the name of each of these pamphlets to find it online.
 
     Next we will talk about life after driving.  There really is such a thing!  Meanwhile.....
....... Drive safely and keep the rubber side down! ~~ Karen

Life After Driving

     For most of us it is difficult to change from the convenience and independence of driving ourselves to relying on some other means to get around our communities.  But when we need to limit or stop our driving, we are faced with a clear choice:  we either find another way to get to the people and places we want to go, or we stop going out.
 
     I have seen this go both ways.  Some of the seniors who are no longer able to safely drive, prefer to give up, stating and thinking that their life is over.  NOT TRUE!!  The convenience of spontaneously jumping in the car to go somewhere is lost, but not the ability to go.
 
     Many prefer to ask family and friends to help get around.  Most communities around the country have other choices ranging from public transportation (the bus or taxi systems for example) to specialized programs for persons wih identified needs such as para-transit and medical transport services.  Some of these are paid services; others rely on unpaid volunteers.
 
     Finding out more about your community choices, even before you need them, can keep you connected to your community and keep you participating in those activities that are important to you.  So many times I have heard "I don't want to be a bother." 

But I believe in paying it forward. Drive for others if you are safely able to provide those services for others now.  Later, when it is your turn to give up driving, you can accept rides with others with a clear conscience.  If you have already reached a point where you need to give up driving, think back to all the things you have done for others and do not feel bad about accepting help.  I know that, for me, accepting help gracefully is very difficult.  Sometimes it is something you can never repay, but you can pass it on in a myriad of different ways to others.
 
     If you are not sure where to find public transportation in your community, go to www.publictransportation.org.  [15] This public transit web site for the public is a great resource.  If you go to the header "Transit Systems", you can locate public transportation systems in your area.
 
     I hope this series has been beneficial to you.  I will further address each of these topics in greater detail at a later date.  Meanwhile...
..... Drive safely and keep the rubber side down! ~~ Karen
 

I didn't know, Karen, until you brought this to us at Lumigrate, that this was a week designated by our national OT association related to driving, so thank you so much! 

It serves as an example of how the 'specialized' everyone is, and now that there is an overwhelming amount of information 'out there' to keep up with on things a person can be interested in and following, it's easier to miss something major like this even within our own profession of occupational therapy!  

I'm sure you'll be including information from AOTA in your series this week, but I wanted to give them a link and credit here as well in case anyone is interested in what this 'OT association stuff' is all about.  The link to their website is: www.aota.org [17] and when I ventured there just now, the older driver was on the landing page as the 'cover story', which didn't surprise me, but it's just so nice to see driving as the central focus  www.aota.org/News/Consumer/Older-Driver_1.aspx [18]   There's a special area of their website related to driving and that you can see from their landing page in the list on the left OR the direct link is: www.aota.org/older-driver [19].  They don't have other areas identified on a separate tab, so this tells you it's a BIG topic they have people coming to their website about.  

As people may or may not know, I'd specialized in driving rehabilitation for a couple of years back around the time of the millenium, and so I'm looking forward to learning what the latest is from this series. When I was hired in late 1998, I scoured the Internet to learn about driving in order to best advise people I would be working with.  

I was astounded to find a report of a case where a neighbor had made a comment to another neighbor about the driving ability/concerns they had about someone in their area. Later, when there was an incident caused by the 'allegedly' problematic driver, guess who was found guilty? The neighbors who talked about it and didn't DO anything were found to be at fault by a state supreme court ruling!  So that is one of the strongest pieces I could contribute to family, friends and most of all the person whose driving priviledges were being evaluated: Do you want your family to have to go through that?

I'd suggest to them, if the were found to not be safe for driving, to put the money they spent monthly/yearly on their automobile and insurance into an account or earmark it (a cookie jar, whatever) and use it for taxis or if possible towncar services who liked to make extra money during the day, as most of their business was nighttime or driving executives in the mornings.  

By setting them up from the very beginning with the ideas of what they could do 'instead of' driving themselves, it helped lower the pressure on them.  Is there a neighbor who might enjoy being treated to a dinner out once a week for having driven you to the store?  Thinking creatively and collaboratively of how people can help each other rather than 'losing something' often helped this challenging time. Sometimes they could use a mobility 'vehicle' of some kind and I'd suggest they purchase one with proceeds from selling the automobile. 

The other document I would show them (which anyone can download for FREE), is the very extensive report that was a collaboration of the AMA (American Medical Association) and the NHTSB (National Highway Transportation Safety Board), and I will provide the highlights of one section of it with a link below.  

I wanted to include though, for those who are reading here, how difficult this can be to solve and why it is I encourage a CDRS and me as a generalist OT to be contacted/consulted with for questions.  It astounded me in 2010 to have to have a conversation with my father's geriatrics specialist and discharge planner from the skilled nursing facility where he was for five weeks after a sudden decline/surgery.  For years I had attempted to get agreement about forcing him to stop driving and could not get agreement from my family; he was driving hours before he had a syncopal episode and collapsed on the floor and almost died before being found 24 hours later.

That fact is what got the doctor to agree to complete the official form to revoke the driving proviledges. However, the doctor's response initially before I informed him of how close in time he was driving to the medical event, said 'can't you just hide the keys or disconnect the battery?'.  Oh, we're playing GAMES now rather than dealing with people above board?  I see, rather than making it legal and protecting both of us in exchange for a piece of paper that takes a few minutes to fill out, you're going to set up something dishonest like you'd do with a CHILD, but we're talking about someone who deserved our utmost respect; our elders!.  

By the way, just months before, my father had also refused Life Alert. He accepted the responsibility of what that might mean to him and nobody else could be harmed; the driving piece was a BIG deal to me and I take it very seriously. I felt badly enough about the horrendous time he had on the floor before he lost consciousness totally; imagine how it would have been had he been injured in a car crash that also involved others?

THAT, my friends is the key to this.  Truly imagining what it would be like if there were an incident and then deciding if it's better to face the situation and the person in question head on and doing the 'right thing'. I think it's the only respectful thing to do!  Frequently it is a spouse and there are children who will get in line and be supportive, so that is my first suggestion.  Families have to come together in agreement however, and reach out to consultants and experts around them if they cannot get that. Unfortunately there is a deterioration in the quality of the 'experts' filling all the seats as we go into serving the increasing number of elderly; the first 'baby boomers' hit 65 in 2011; this is just the tip of the iceberg, or rather picture a bulge the size of a tennis ball of 'demand' trying to fit through a garden hose of 'supply'.   

People with cognitive impairment do not make good judgements and as mature family members and concerned friends, neighbors and citizens we owe it to them to fill in for that gap when they are unable.  The process is similar to an 'intervention' for substance abuse; everyone has to be involved on the same page or else 'splitting' can and will occur.  If everyone agrees to stand the line, then it will work. And we have someone on Lumigrate who is able to do interventions for other things, I would imagine she'd be able to guide people who wanted her expertise in this type of advise as well. 

In my family I have gone from being the 'good child' to the 'bad cop'.  The change in me as I went into adulthood and middle age was not one that my family ever got used to, and that lead to more difficulties in a way.  So please look at that type of dynamic in your family as well.  That change of roles as I matured professionally coincided with my father's medical impairment onset and lead to a unique situation in my case which I want others to think about in their family systems.  "Systems theory" is a whole topic unto itself but of value for therapists and driving specialists to be versed in when they are dealing with family systems. And certainly those in families! (Which is about all of us... )

When it is adult children dealing with aging parent(s), it is very difficult for the families to 'change the pecking order' (parent as child, child as parent) as time goes on and things change. But that is what must happen.  And if there are other motives related to properties and assets with aging or ill family members, that becomes an additional factor, from my observations over the last decade and a half working with the elderly population in a variety of professional settings. It becomes very complex and I want people to know the team of experts available at Lumigrate who consult with people coast to coast.  If anyone has a question, Contact Us with a few details and we will respond and get an answer / direction to you.   

Here is the 'crux' of the information from the PDF I downloaded by Google searching on "AMA, medically impaired driver".

“ Duty to Protect" the Patient

Protecting the patient’s physical and mental health is considered the physician’s primary responsibility. This includes not only treatment and prevention of illness, but also caring about the patient’s safety. With regard to driving, physicians should advise and counsel their patients about medical conditions and possible medication side effects that may impair one’s ability to drive safely.

 

Certain states have enacted mandatory reporting requirements, which place the physician in danger of both civil and criminal liability for failure to report.131 Wording in the Pennsylvania law has led the Pennsylvania DMV to state that physicians who do not report “could be held responsible as a proximate cause of an accident resulting in death, injury or property loss caused by your patient; the Pennsylvania statute further states that providers who do not comply with their legal requirement to report may be convicted of a summary criminal offense”.132 Some cases illustrate that a physician’s failure to advise the patient about such medical conditions and medication side effects can be considered negligent behavior.133

 

The Public

In addition to caring for their patients’ health, physicians may, in certain circumstances and jurisdictions, have some responsibility for protecting the safety of the public.134,135 In certain states, physicians have been found liable for third-party injuries because they failed to advise their patients about medication side effects,136 medical conditions,137 and medical devices138 that may impair driving performance thus causing harm to those other than the patient.

 

Maintaining patient confidentiality

Patient confidentiality is the right of an individual to have personal, identifiable medical information kept private; these protections are enumerated in the federal statute, the Health Insurance Portability and Accountability Act of 1996, or HIPAA.139 Patient confidentiality is defined as the physician’s ethical obligation to keep information about the patient and his/her care unavailable to those—including the patient’s family, the patient’s attorney, and the government —who do not have the authorization to receive or review this information.140,141

 

Patient confidentiality is crucial within the physician-patient relationship because it encourages the free exchange of information, allowing the patient to describe symptoms for diagnosis and treatment.142 Without belief in the patient confidentiality of their care, individuals may be less likely to seek treatment, disclose information for effective treatment, or trust the health care professional.143

 

The need for patient confidentiality cannot be considered absolute; a patient is entitled to freely disclose his or her symptoms and condition to his or her physician in confidence except where the public interest or the private interest of the patient so demands, and thus a patient possesses a limited right to patient confidentiality in extrajudicial disclosures subject to exceptions prompted by the supervening interest of society.144 Thus, patient confidentiality does not necessarily protect the physician in the impaired driver situation.145

www.ama-assn.org/ama1/pub/upload/mm/433/older-drivers-chapter7.pdf [20]

 My experience was that what happens in allopathic circles where the doctor is involved in driving decisions is the provider becomes 'the bad guy'.  So it is best for them to be able to refer and defer to someone else related to driving to let them know what they found upon assessment. That way, it doesn't get in the way of the doctor/patient relationship.   For the driving specialist, such as a CDRS, OTR, etc, we then are the 'good guy' to the family who has a 'out' by saying it was the decision of the expert.  However, many people don't have access to a CDRS/driving expert and might look at how to work around that through what I have hopefully thoroughly described here.

I think it's really important that there be someone in every community to is available to provide that function so the doctor and her or his staff can remain the trusted 'good guy'. And since that's not 'reality', you, Karen, are available to the Lumigrate community -- so anyone anywhere can turn to you and to Lumigrate to help them with this very critical aspect of health and wellness and safety with our daily living activities. Again, if anyone has questions for Karen she has contact information in her signature of you can do a Contact Us and it will come through Lumigrate and get routed and responded to. 

Be safe, don't be sorry ~~

~~ Mardy